Emanuela Altobelli

Readmission Rate and Causes at 90-Day after Radical Cystectomy in Patients on Early Recovery after Surgery Protocol.

Background: Radical cystectomy (RC) is associated with high risk of early and late perioperative complications, and readmissions. The Enhanced Recovery After Surgery (ERAS) protocol has been applied to RC showing decreased hospital stay without increased morbidity. Objective: To evaluate the specific causes of hospital readmissions in RC patients treated before and after adoption of an ERAS protocol at our institution. Methods: We retrospectively evaluated the outcome of 207 RC patients on ERAS protocol at the Stanford University Hospital from January 2012 to December 2014. We focused on early (30-day) and late (90-day) postoperative readmission rate and causes. Results were compared with a pre-ERAS consecutive series of 177 RC patients from January 2009 to December 2011. Results: In the post-ERAS time period a total of 56 patients were readmitted, 41 within the first 30 days after surgery (20%) and 15 within the following 60 days (7%). Fever, often associated with dehydration, was the most common reason for presentation to the hospital, accounting for 57% of all readmissions. At 90 days infection accounted for 53% of readmissions. Of all the patients readmitted during the first 90 days after surgery, 32 had positive urine cultures, mostly caused by Enterococcus faecalis isolated in 18 (56%). Readmission rates did not increase since the introduction of the ERAS protocol, with an incidence of 27% in the post-ERAS group versus 30% in the pre-ERAS group. Conclusions: Despite accurate adherence to most recent perioperative antibiotic guidelines, the incidence of readmissions after RC due to infection still remains significant.

Urodynamic abnormalities in toilet trained children with primary vesicoureteral reflux.

PURPOSE We investigated associated urodynamic abnormalities in toilet trained children with vesicoureteral reflux. MATERIALS AND METHODS A total of 298 toilet trained children with primary vesicoureteral reflux underwent urodynamic evaluation. Urodynamic parameters were reviewed and correlated with age, gender, presence of lower urinary tract symptoms and reflux severity. RESULTS Symptomatic lower urinary tract symptoms were present in 111 children (37.2%, group 1). Children with lower urinary tract symptoms had significantly decreased severity of vesicoureteral reflux compared to children without these symptoms (187 patients, group 2). The majority of the patients had normal early bladder compliance regardless of presence of lower urinary tract symptoms or reflux grade. On the other hand, decreased late bladder compliance was more common in group 1 vs group 2. Ratio of cystometric bladder capacity to expected bladder capacity was higher in group 2. Detrusor overactivity was observed in 28.5% of the children, and the incidence was significantly higher in group 1 vs group 2, and in mild vs moderate or severe reflux. Dysfunctional voiding from bladder sphincter dyscoordination was seen in 32% of children 2.5 to 4 years old with vesicoureteral reflux and lower urinary tract symptoms, compared to 8% in children 5 to 16 years old. CONCLUSIONS The presence of lower urinary tract symptoms in children with vesicoureteral reflux correlated well with some urodynamic findings suggestive of overactive bladder and negatively correlated with reflux severity. In contrast, dysfunctional voiding was more common in younger children with reflux and lower urinary tract symptoms. These findings suggest that treatment of voiding dysfunction should be directed toward the specific type of abnormality in children with vesicoureteral reflux.

Indication to Open Anatrophic Nephrolithotomy in the Twenty-First Century: A Case Report

Introduction. Advances in endourology have greatly reduced indications to open surgery in the treatment of staghorn kidney stones. Nevertheless in our experience, open surgery still represents the treatment of choice in rare cases. Case Report. A 71-year-old morbidly obese female patient complaining about occasional left flank pain, and recurrent cystitis for many years, presented bilateral staghorn kidney stones. Comorbidities were obesity (BMI 36.2), hypertension, type II diabetes, and chronic obstructive pulmunary disease (COPD) hyperlipidemia. Due to these comorbidities, endoscopic and laparoscopic approaches were not indicated. We offered the patient staged open anatrophic nephrolithotomy. Results. Operative time was 180 minutes. Blood loss was 500 cc. requiring one unit of packed red blood cells. Hospital stay was 7 days. The renal function was unaffected based on preoperative and postoperative serum creatinine levels. Stone-free status of the left kidney was confirmed after surgery with CT scan. Conclusions. Open surgery can represent a valid alterative in the treatment of staghorn kidney stones of very selected cases. A discussion of the current indications in the twenty-first century is presented.

Accuracy of elastic fusion biopsy in daily practice: Results of a multicenter study of 2115 patients

To assess the accuracy of Koelis fusion biopsy for the detection of prostate cancer and clinically significant prostate cancer in the everyday practice.

MP03-17 MRI-BASED NOMOGRAM TO PREDICT THE PROBABILITY OF PROSTATE CANCER DIAGNOSIS WITH MRI-US FUSION BIOPSY

INTRODUCTION AND OBJECTIVES: Prostate cancer (PCa) remains the only solid organ tumor that is diagnosed by a non-targeted sampling method. Recently, multi-parametric MRI (MP-MRI) in conjunction with an MRIultrasound (US) fusion guided biopsy (bx) has demonstrated improved PCa detection. Unfortunately, this technology has been limited to tertiary care centers. Therefore, we sought to compare cognitive versus targeted software to assess the ability of cognitive registration to disseminate more readily into the community. METHODS: Consecutive patients underwent an MRI-US fusion prostate bx for elevated PSA, abnormal DRE, active surveillance or prior negative bx with a persistently elevated PSA. All subjects underwent pre-bx MP-MRI and lesions visible on MRI were graded using the PI-RADS version 2 classification system. The UroNav bx tracking system was used to fuse the stored MR images with real-time US generating a 3D model, which was then used to sequentially perform cognitive, targeted, and standard 12 core systematic biopsies in an office setting under local anesthesia. Descriptive statistics included patient characteristics and univariate analysis was done using logistic regression analysis to detect the associations between presence of cancer, clinically significant cancer, demographic variables, and bx method. Signed rank test was used for paired comparisons amongst bx method. RESULTS: 44 patients (median age 66 yrs, median PSA 6.4) underwent an MRI-US fusion bx between July 2014 and October 2015 with an overall CDR of 59%. Cognitive CDR was 40.9% with 25% being clinical significant disease. The targeted CDR was 27.3% with 22.7% being clinically significant disease. Overall, the cognitive approach had a sensitivity of 69.2% (95% CI: 50%, 88%) whereas the targeted approach had sensitivity of 46.2% (95% CI: 26%, 67%). Furthermore, the targeted approach missed 8 cancers when compared to the cognitive approach, whereas, the cognitive approach missed 2 cancer when compared to the targeted approach. The difference in sensitivity is most pronounced when comparing standard and targeted methods (p1⁄40.02) and approaches significance when comparing cognitive and targeted methods (p1⁄40.11). CONCLUSIONS: MRI-US fusion targeted software when compared to the cognitive platform, was not found to have higher cancer detection rate nor sensitivity. We believe this highlights the importance of the MRI itself, rather than the platform used.

MP03-09 MRI-BASED NOMOGRAM PREDICTING THE PROBABILITY OF DIAGNOSING A CLINICALLY SIGNIFICANT PROSTATE CANCER WITH MRI-US FUSION BIOPSY

INTRODUCTION AND OBJECTIVES: Multiparametric MRI (mpMRI) improves the detection of significant prostate cancer (PC) and extraprostatic extension (EPE). We combined pre-biopsy mpMRI data and clinical parameters to develop a risk model (RM) to predict individual side-specific risk of EPE on radical prostatectomy (RP). METHODS: MRI and clinical parameters of 132 men who underwent mpMRI fusion-biopsy and RP were analysed as training set. The RM was validated prospectively in 132 consecutive patients. Multivariate regression analysis was used to determine EPE predictors for RM development. The calibration of the RM was analysed using a calibration plot. The accuracy was compared to digital rectal examination (DRE), ESUR MRI criteria for EPE alone and the nomogram for side-specific EPE prediction of Steuber et al., using receiver operating characteristics (ROC) in training and validation set. Differences between the ROC curves were analysed using Likelihood ratio tests. RESULTS: Primary Gleason pattern on biopsy on specific side, ESUR MRI criteria of side-specific lesion, PSA-density, clinical T-stage, lesion volume in milliliter and capsule contact length in millimeter on MRI were significant EPE-predictors and were included in the RM (Figure a). The calibration plot of the RM showed that predicted and actual probabilities were close (slope 1.12)(Figure b). ROC area under the curve (AUC) for the RM was significantly larger in both sets (0.88 and 0.84), compared to DRE (0.69, p1⁄40.004, 0.66, p<0.001) and the risk model of Steuber et al. (0.77, p1⁄40.009, 0.71, p1⁄40.006). Compared to ESUR criteria (AUC 0.87 and 0.80), the AUC was only significant larger in the validation set (p1⁄40.03) (Figure c/d). CONCLUSIONS: The RM, incorporating clinical and standardized MRI parameters performed significantly better compared to a renowned risk model, ESUR MRI criteria and clinical parameters alone. Thus, it provides accurate individual risk stratification of side-specific EPE of prostate cancers prior to RP.

Bilateral ureteral tapering and secondary ureteroneocystostomy for late stenosis in a patient with bladder extrophy.

Objective: To report a case of severe hydronephrosis 20 years after bladder exstrophy (BE) repair, managed by bilateral ureteral tapering and secondary ureteroneocystostomy. Case Presentation: A 21-year-old woman with a history of BE and ureteral reimplantation, presented with hematuria-dysuria syndrome and recurrent febrile urinary tract infections. After counselling, she elected to undergo bilateral ureteral tapering and second ureteroneocystostomy. Conclusion: Hydronephrosis secondary to ureteralvesical stricture in BE patients can be successfully managed with ureteral reimplantation associated to ureteral tapering even after a prior reimplantation.